To protect personal information (PPI), all IVR callers must go through the caller verification process before receiving information. Callers are verified based on information available on our local system so it is possible that some out-of-state callers may not be able to use the IVR.

Eligibility, claim status and our top 10 benefits are available 24 hours a day EXCEPT for Sunday mornings from 4:00 AM – 9:00 AM Eastern Time and during scheduled outages for system maintenance.

IVR quotes the 10 benefits requested most often from Customer Service.

For your convenience, the following worksheets are available for use when using IVR. The worksheets are set-up in the order that information is presented during the call.1

S

CLAIM STATUS

ELIGIBILITY

Enter the Subscriber ID #:

R

Patient’s date of birth:

Eligibility Effective Date:

Plan Name2

Policy Covers2

Enrollment Code2

Grace Period?3

Standard Option

Basic Option

Subscriber only

Subscriber & Family

104

105

111

112

Standard Option: Both Preferred and Non-preferred providers can be used, however, out-of-pocket expenses are lower when Preferred providers are used. Standard Option has a calendar year deductible for some services and a $20 copayment for office visits to Preferred primary care providers ($30 for specialists).

Basic Option Basic Option does not have a calendar year deductible. Most services are subject to copayments ($25 for primary care providers and $35 for specialists). Members do not need to have referrals to see specialists. Preferred providers must be used to be eligible for benefits, except in certain circumstances, such as emergency care.

Eligibility, Benefits and Claim Status are options available to FEP providers (FEP members are offered eligibility and benefits only)

Since Claim Status information is only offered to providers, you must use the provider option (#2) when entering the IVR

Due to HIPAA regulations, all callers must be verified.

It is important to remember that you can hear only the claims that were submitted under the tax ID number with which you verify

If you use more than one TIN to submit claims, you need to redial the IVR and re-verify with the other TIN before hearing claims submitted under those numbers

This is a speech recognition system, but it also supports the use of the telephone keypad to perform tasks such as entering the tax ID number and dates and to reply yes (#1) or no (#2) to questions

You MUST speak the member’s Subscriber ID number beginning with the letter “R” e.g. R12345678 (cannot use the keypad and cannot omit the letter R)

Dates can be stated as April 4, 2010 or 4/4/2010 or entered using the keypad as an eight digit number (8 digits) 04042010, but dates are not recognized if a 2 digit year is spoken or typed, e.g. spoken 4/4/10 or typed 4410

It is not necessary to wait for the menu option to finish before making a choice

A whole phrase is not required, for example, the IVR will ask if you want to search for claims by specific date or a range of dates. It will prompt you to say “specific date” or “month and year of service”. Simply say “date” or “month” (be sure to include the whole year, 2005 not 05, when prompted for the date)

Because the claims database is so large, we want to verify that we have the date(s) correct before doing a search so the IVR will always ask for verification of the date before searching. A search by month will always speak the date range for a whole month, e.g. September 1, 2010 – September 30, 2010, even if you are calling on September 15th

If more than three claims are found, you will be asked if you want to narrow the search by total charge

If the claim was denied and then paid, only the most recent iteration of the claim is spoken

If there are multiple denials or multiple paid claims for the same date, all claims are spoken

Once the IVR begins quoting a series of claims, say “next claim” or press the pound key (#) at any time to move on to the next claim

If the IVR cannot find a claim with the exact total charge, it will search for the claim that most closely matches the request

Eligibility is always quoted before a benefit is spoken, so whether you say “eligibility” or “benefits”, the quote will start with eligibility

Currently, nine (9) benefits are quoted (speak the benefit name or use the numeric equivalent from the job aid). Three facility benefits (claims will be billed on a UB04) and nine professional benefits (claims will be billed on a HCFA1500) :

Facility Inpatient Stay

Facility Outpatient Medical

Facility Outpatient Surgical

Professional Office Visit

Professional Diagnostic

Professional Preventive Care (both Adult and Child benefits are quoted, but you do not need to say adult/child because the IVR will compute the patient’s age then quote the correct benefit based on the age)

Professional Physical, Speech and Occupational Therapy (no need to say all three, just say professional speech therapy or professional PT, etc.)

Professional Chiropractic

Professional Surgery

1 Except for Chiropractic and PT/OT/ST benefit limits; these are found at the end of the form.

2 Check one

3 Under some circumstances, terminated members may have a 31 day grace period. If a grace period applies to your patient, the IVR will advise you.